Provider First Line Business Practice Location Address:
122 PEACHTREE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELIZABETHTOWN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42701-1650
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-769-5652
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/27/2008